Form 127
SMALL CLAIMS FINANCIAL DISCLOSURE STATEMENT
DOCKET NO. COUNTY SELECT
BRING COMPLETED FORM TO HEARING
COUNTY
(w)
Name Street Address Single Married Divorced/Separated
Birth Date City, State, Zip Code
Phone (H)
HOUSEHOLD MEMBERS
WORKING NOT WORKING
MONTHLY EXPENSES
Loans: Car Home Mortgage Other Taxes & Insurance Rent Food Utilities Clothing Medical Other TOTAL MONTHLY EXPENSES $ $ $ $ $ $ $ $ $ $ $ /mo. /mo. /mo. /mo. /mo. /mo. /mo. /mo. /mo. /mo. /mo.
MONTHLY INCOME OF HOUSEHOLD MEMBERS
Employer Nature of Work
ASSETS
Cash on Hand Institution Checking Savings $ $ $ $ $
$
Balance
Monthly Gross Wages Employer
/mo. Securities Other
Nature of Work Monthly Gross Wages /mo. TOTAL ASSETS
VEHICLES- (Include Recreational Vehicles)
Veteran's Benefits Public Assistance Workers' Comp. Unemployment Pension Rents Social Security $ $ $ $ $ $ $ $ /mo. /mo. /mo. /mo. /mo. /mo. /mo. /mo. Fair Market Value LESS: Outstanding Mortgage Equals Net Worth $ $ $ Year Year Year Make Make Make Model Model Model (NET) Value $ Value$ Value $
REAL ESTATE
Location:
TOTAL MONTHLY INCOME
YOU MUST SIGN THIS DOCUMENT IN THE PRESENCE OF A NOTARY PUBLIC.
I make the above answers to the questions contained herein under PENALTY OF PERJURY. Defendant's Signature The above individual personally appeared before me and made oath to the truth of the answers in response to the questions.
Date
Signature of Notary
Date
Expiration Date
Rev. 12/02 SML